Provider Demographics
NPI:1134677644
Name:PROMD
Entity Type:Organization
Organization Name:PROMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TELISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-567-1808
Mailing Address - Street 1:5058 CITY LINE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:608 BERKLEY ST
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1414
Practice Address - Country:US
Practice Address - Phone:832-567-1808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD456019261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1306257001Medicaid
PA1306257001Medicare UPIN
PA1306257001Medicaid